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CASE REPORT |
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| Year : 2009 | Volume
: 54
| Issue : 5 | Page : 14-15 |
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| Marjolin ulcer with multifocal origin |
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Sudip Das, Alok Kumar Roy, Arunasis Maiti
Department of STD and Leprosy, NRS Medical College and Hospital, Kolkata, India
Correspondence Address:
Sudip Das
NRS Medical College and Hospital, Skin, STD and Leprosy Department, Room no - 18 and 19, OPD Building, NRS Medical College and Hospital, Kolkata - 14
India
 Source of Support: None, Conflict of Interest: None  | Check |
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 Abstract | | |
Marjolin ulcer developed from a twenty years old post burn scar. The patient presented with chronic ulceration followed by multifocal development of squamous cell carcinoma with different growth pattern. One nodular lesion grew rapidly to produce a large lesion with history of a little bleeding after trauma but without any pain. Excision followed by skin grafting resulted in good cosmetic scar.
Keywords: Marjolin ulcer, multifocal origin, post burn scar
How to cite this article:
Das S, Roy AK, Maiti A. Marjolin ulcer with multifocal origin. Indian J Dermatol 2009;54, Suppl S1:14-5 |
| Introduction | |  |
Marjolin ulcer (MU) is a malignant transformation of a chronic ulcers, sinus tract, fistula or long standing scar of various etiologies. As most of these cancers are squamous cell types, today the term Marjolin ulcer is generally used for squamous cell carcinoma (SCC) arising on scar tissue. It is usually a slow growing tumor. Marjolin ulcer is slightly different from typical SCC because its edge is not always raised and everted and may present as an unusual nodule at the border of scar tissue. Marjolin ulcer is radio resistant as extensive fibrosis makes it relatively less vascular.
| Case History | | |
This report presents the case of a 55-year-old woman with chronic ulceration of a post burn scar of the leg 20years back. She presented with round ulcer (7 cm ´ 7cm) over left anterolateral aspect of leg (15 cm below the tibial tuberosity) for the last one year. The margins spread very slowly and was elevated from the surface. A nodular lesion developed over its margin after a few months. It was painless and there was history of very little bleeding after trauma. On examination, ulcer margin was everted and rolled out at some places and flat at other areas [Figure 1]. There was a nodule (1 cm × 1 cm) at the upper margin. Floor was covered with yellow slough and crust with very little oozing. Base was mildly indurated without any tenderness. Surrounding skin was depigmented; there was no palpable draining lymph node. Histology from incisional biopsy from the nodular area and one from ulcerated everted margin shows atypical pleomorphic epithelial pearl formation with infiltration [Figure 2]. It was diagnosed as infiltrating well differentiated squamous cell carcinoma. Patient was sent to plastic surgery department where excisional biopsy followed by skin grafting done.
| Discussion | | |
The classic description of Marjolin ulcer was published by Jame Nicholas Marjolin in 1828. [1] Now-a-day's post burn scar is the most common site of development of Marjolin ulcer. Malignant degeneration of burn scar has been reported by Celsus as early as in the 1 st century. According to duration of latency, Marjolin ulcer is subdivided into two variants-acute with latency of 1 year and chronic with average latency of 36 years [2] but it may develop even after 50 years. [3] Clinically two different growth patterns have been described - commonly, flat, indurated, infiltrative, ulcerative carcinoma and less frequent, exophytic papillary form. In our case the patient presented with infiltrative ulcerated growth at one place and nodular growth in other place and intervening margin with little activity. Although the nodule was very slowly increasing in size, the infiltrative ulcerated margin was increasing more rapidly which brought the patient in our OPD. So two different patterns were present in the same scar along with more or less normal margin in between which is consistent with focal nature of maligning change in burn scar. There are reports of cases with multiple punch biopsies being negative but a complete excision revealing the dignosis of squamous cell carcinoma. [4] Because of the focal nature of the malignant changes in burn scar, excisinal biopsy should be performed.
| Conclusion | | |
Marjolin ulcer developing after 20 years of post burn scar is rare but can develop malignant changes. So, any case of long standing burn scar developing into ulcer should be biopsied (incisional or excisional) and follow-up to be done regularly to rule out any malignant degeneration. Regional lymph node should be examined. A nodular growth at the margin of a scar with mild ulceration may be early presentation of Marjolin Ulcer.
| References | | |
| 1. | Das S. A manual of clinical surgery; 4 th ed. Calcutta: Feb. 1996; p. 53.  |
| 2. | Horch RE, Joern Stark GB, Beier JP. Unusual explosive growth of the scalp after electrical burn injury and subsequent coverage by sequential free flap vascular conection: A case report. BMC Cancer 2005;28:150. |
| 3. | Garzon R, Burgos EB, Garzón FL, Cippitelli L, de Cabalier ED, Cabalier LR. Marjolin Ulcer; Rev Fac Cien Med Univ Nac Cordoba 2001;58:93-7. |
| 4. | Phillips TJ, Salman SM, Bhawan J, Rogers GS. Burn scar carcinoma diagnosis and management. Dermatol Surg 1998;24:561-5. [PUBMED] |
[Figure 1], [Figure 2] |
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